We commend Cheng et al1 on their significant study implementing a cardiac troponin I (cTnI) surveillance program for patients receiving immune checkpoint inhibitors (ICIs). Their work provides important real-world evidence supporting biomarker monitoring and demonstrates that proactive screening can lead to earlier diagnosis, shifting the paradigm from reactive treatment to proactive surveillance.2
One of the study’s most valuable contributions is its pragmatic, symptom-based triage model, which effectively risk-stratifies patients while guiding resource allocation and preventing unnecessary interruptions to cancer therapy. However, the model’s reliance on 24/7 cardio-oncology team availability highlights a critical barrier to widespread adoption, raising concerns about implementation feasibility in resource-limited settings and the potential for exacerbating health disparities.3 Moreover, a key limitation is the exclusive use of cTnI. Growing evidence suggests that cardiac troponin T (cTnT) may offer improved prognostic value in ICI-related myotoxicity, which presents as a systemic myositis-myocarditis overlap syndrome.4 As inflamed skeletal muscle can release cTnT but not cTnI, cTnT may better reflect the total cardiomuscular disease burden that determines prognosis.4,5 This suggests an opportunity to refine surveillance protocols, potentially using cTnI for its high cardiac specificity in initial screening, followed by cTnT and creatine kinase measurements for prognostication in patients with elevated cTnI.1,4,5
The work by Cheng et al1 represents a seminal observational study that advocates for surveillance-based approaches.1 It sets the stage for an essential next step: a prospective, multicenter, randomized controlled trial. Such a trial is necessary to definitively establish whether biomarker screening improves clinical outcomes, including cardiovascular mortality and overall survival, and to understand if this practice should be the standard of care.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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